Insurance Full Coverage Form

INSURANCE FULL COVERAGE FORM

Applicant / Insured Information

Applicant Name:

Date of Birth:

Policy Details

Policy Type: Auto Home Life Commercial Other

Policy Period: Effective From through

Coverage Selections

Indicate coverages requested (check all applicable and provide limits where required):

Liability Coverage   Limit: $

Collision Coverage   Deductible: $

Comprehensive Coverage   Deductible: $

Uninsured/Underinsured Motorist   Limit: $

Medical Payments   Limit: $

Personal Injury Protection (PIP)   Limit: $

Exclusions and Limitations

The insurer shall not be liable for loss or damage resulting from: (a) intentional acts or willful misconduct of the insured; (b) wear and tear, mechanical or electrical breakdown, inherent vice; (c) racing, speed contests, or use of the insured property in the commission of a felony; (d) nuclear hazard or war risk; or (e) coverage specifically excluded in the policy declarations. Coverage for certain risks may be subject to specific endorsements, sublimits, waiting periods, or further underwriting review.

I acknowledge that I have read and understand the exclusions and limitations stated above and that additional exclusions may appear in the policy form to be issued. Acknowledged

Beneficiary Designation (If Applicable)

Apply beneficiary information to applicable coverages: Yes

Claims History and Previous Losses

Have you had any insurance claims or losses in the past five (5) years? Yes No

Declarations, Certifications and Notices

By signing below, the applicant certifies under penalty of perjury that the information provided in this application is complete, true and correct to the best of the applicant's knowledge. The applicant agrees that this application and any statements made herein shall form the basis of any policy issued and may be relied upon by the insurer in underwriting and rating. The applicant further authorizes the insurer to obtain and exchange information necessary for underwriting, claim investigation and fraud detection, including motor vehicle records, credit information, and prior claim history.

Premium payment, acceptance of risk, and issuance of any binder or policy is subject to underwriting approval. Coverage, limits, endorsements and exclusions will be as set forth in the policy issued. Coverage is not in effect until confirmed by the insurer in writing or by issuance of a policy or binder.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be subject to civil and criminal penalties under applicable law.

Acknowledgment: I acknowledge and accept the declarations, certification, and notices above.

Authorization and Signature

I authorize the insurer to verify any information provided and to obtain any records required for underwriting and claim handling. I understand that failure to disclose a material fact may result in denial of coverage or rescission of the policy.

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